Each month, the Editors of the Journal of Allergy and Clinical Immunology will select two JACI articles for discussion. Readers are invited to send in their questions and comments, which will be addressed by the authors. Articles highlighted on this blog are available free of charge from the links in each post.

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Thursday, March 23, 2017

Novel baseline predictors of adverse events during oral immunotherapy in children with peanut allergy

Food allergy is a huge problem
affecting 3 to 8% of school-age children.
So far, avoidance and supportive management have been the mainstays of
therapy, but this is rapidly changing with studies showing the efficacy of oral
immunotherapy (OIT), especially for peanut allergies. In peanut OIT, gradually increasing doses of
peanut are given as part of the buildup, with steady doses given during
maintenance. The hope is to desensitize
the immune system so that reactions are not as severe. In this month’s issue of JACI, Virkud and
colleagues discuss the safety of oral immunotherapy to peanut by examining 104
patients from 3 peanut OIT trials (J Allergy Clin Immunol 2017; 139(3): 882-888). They
look at the past medical history, parental reports, daily symptom diaries, and
relationship to dose escalations to determine the risks and predictors of
adverse effects (AEs).

The rate of AEs was high, with 80%
experiencing at least 1 episode, and over 90% of these occurring at home. 42% of AEs were systemic reactions, but fewer
than 50% received epinephrine, indicating a need for better patient
education. About half of these AEs were
gastrointestinal, and half of the patients who dropped out did so due to these
gastrointestinal AEs; this amounted to 10% of all enrolled patients.

Overall, allergic rhinitis and the
wheal size on peanut skin prick testing (SPT) were significant predictors of
AEs. Allergic rhinitis approximately
doubled the likelihood of having an AE, and seemed to explain why there was a
higher rate of AEs during the spring and the fall. Asthma was also predictive of AEs during
maintenance, but not in the buildup phase.
Gastrointestinal AEs, like abdominal pain, nausea, vomiting, difficulty
swallowing, and diarrhea, were also associated with the peanut SPT wheal
size.

While there remains a lot to be
learned about oral immunotherapy, this study helps to determine who would be
the best candidates for this promising means of treating food allergies. Virkud and colleagues conclude that until
there are rigorous well-designed and controlled trials, avoidance should remain
the current standard of care.